Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

RCE 2021 > Neurologic Emergencies > Flashcards

Neurologic Emergencies Flashcards

1
Q

Status epilepticus definition

A

5+ mins of clinical or electrographic seizure activity OR 2+ seizures without recovery in between

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Refractory status epilepticus

A

Failure of benzo + 1 AED
In 30% patients
20% die

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

SE Rapid initial management

A
  1. Airway - oral, lateral decubitus
  2. Breathing - bag mask, O2, sat probe, RT
  3. Circulation - cardiac monitor, IV access
  4. Check glucose
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

SE Initial management

A

1 abortive and 1 maintenance drug

Abortive - early

  1. Lorazepam 0.1 mg/kg
  2. Diazepam 0.2 mg/kg
  3. Midazolam 10 mg

Maintenance

  1. Phenytoin - 20 mg/kg
  2. Fosphenytoin 20 mg/kg
  3. Valproic acid 40 mg/kg
  4. Levetiracetam 60 mg/kg
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Refractory SE Management

A
  1. ICU
  2. Midazolam infusion
  3. Propofol infusion
  4. Pentobarbital infusion
    Aim for burst suppression for 24 hr before taper
    Monitor for NCSE with continuous EEG
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

SE Investigations

A

Labs
Glucose, ABG, lactate (up), CBC (inc WBC), lytes (hypoK), extended lytes (all hypo), Cr up, NH4 up, tox screen Les, AED level (don’t tx level), prolactin up, beta HCG

Imaging

  1. CT head (tumor, pus, blood)
  2. MRI brain (cortical lesion)
  3. EEG
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

SE Tx Cause

A

Metabolic

  • Hypoglycemia - thiamine, D50
  • Restart missed AEDs
  • Tx withdrawal
  • Tx toxicity
  • Correct lytes -Na, Ca, Mg

Structural

  • Meningitis
  • Encephalitis HSV1>2
  • Stroke
  • CVT
  • Ischemic encephalopathy
  • HTN - PRES
  • Autoimmune
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Epilepsy definition

A

2+ unprovoked seizures >24 hr apart OR
1 unprovoked seizure with >60% recurrence risk OR
Epilepsy syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Focal seizure

A
  • Aware or impaired awareness
  • Motor or non motor onset
  • Focal to bilat tonic clonic

EEG - focal IEDs, slowing

Rx - epilepsy surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Generalized seizure

A

Motor - tonic clonic, myoclonic, atonic, tonic, clonic
Non motor - absence

EEG - generalized spike and wave

Rx

  1. AEDs
  2. Vagal nerve stimulator
  3. Ketogenic diet
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Unknown seizures

A

Motor or non motor

Tx
Broad spectrum AEDs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Seizure features vs other causes

A 
Prodrome/Risks
- Sleep deprived, from sleep, photic stimulation, hyperventilation, alcohol use
During spell
- Positive sx
- Vocalization
- Deju vu
- Epigastric rising
- Head turning
- Incontinence
- Flushing
- Tongue biting
Postdromal
- Tongue biting
- Confusion, somnolence
- focal neuro deficit
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Syncope features vs. other causes

A 
Prodrome/risk
- Light head, sweat, sit/stand, defecation/micturition, palps
During spell
- Brief convulsions
- Pallor, diaphoresis
Postdromal
- Alert
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

TIA features vs. other causes

A 
Prodrome/risk
- CV risk factors
During spell
- Negative symptoms
- Sudden onset
- Max deficit at onset
- <10 mins
Postdromal
- Alert
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Migraine aura features vs. other causes

A 
Prodrome/risk
- FHx
- Motion sickness, cyclical vomiting, adverse childhood experience
During spell
- Gradual migration of sx over 5-60 mins
- Scintillating scotomas
- Paresthesias
- Positive and negative sx
Postdromal
- Sev, unlit throbbing HA
- Photo/phono/osmophobia
- N/V
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Risk of recurrence

A

21-45% after first - greatest in first 2 years
60%+ if abnormal EEG or MRI

EEG

  • Routine low yield ~30%
  • 50% within 24 hrs event
  • 50% sleep deprivation
  • 70% serial EEGs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

AED Options - Broad

A 
Valproate
Lamotrigine
Levetiracetam
Clonazapam
Clobazam
Topiramate
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

AED Options - Focal

A 
Avoid in idiopathic generalized:
Carbamazepine
Oxcarbazepine
Eslicarbazepine
Phenytoin
Gabapentin

Okay:
Phenobarbital
Pregabalin
Lacosamide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

AED Options - Absence

A

Valproate

Ethosuximide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

AED Options - Myoclonic

A

Valproate

Levetiracetam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

AED Tolerability and other SFx

A 
SCARED-P
Sedation
Cog impairment
Ataxia/dizzy
Rash
Emesis/GI
Diplopia/visual change
Pregnant - NO VALPROATE

Other

  • OP
  • HypoNa - carb, oxcarb, eslicarb
  • Psych - levetiracetam
  • SJS - carb, oxcarb, pheny, lamo
  • PR long - lacosamide
  • Weight gain - VA
  • Weight loss - topi
  • CI - topi, clobazam
  • Sedating - clob, phenobarbitals
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

AED Adherence and cost

A

BID>TID

Newer most expensive than older

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

AED in pregnancy

A

Levetiracetam

Lamotrigine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

AED Interactions

A
  • Renal - levetiracetam

- Valproate CYP inhibitor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

AED Mood stabilizers

A

Valproate
Lamotrigine
Carbamazepine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Epilepsy Safety/Driving

A
  • Avoid climbing, swimming, driving
  • MedicAlert
    Driving
  • 1st seizure unprovoked = 3 months
  • Epilepsy - 6 mos seizure free on meds
  • Medication change - 3 mos
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Epilepsy non pharm management

A
  • Stop alcohol and drugs
  • Sleep hygiene
  • Trigger avoidance
  • Screen anxiety, dep, SI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

GBS Defn

A

Acute monophasic inflammatory demyelinating polyradiculoneuropathy
Causes sensory loss, ascending paralysis, areflexia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

GBS Risk Factors

A

Infection - C jejeni, flu, HIV, Zika

Influenza&raquo_space;> flu shot

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

GBS Treatment

A 
Nonambulatory patients within 4 weeks of symptoms
1. IVIG - 2g/kg over 2-5 d
OR
2. PLEX
- No steroids
- Don't use both
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

GBS Acute management

A
  1. ABCs - tele, BP, FVC q4h
  2. Intubate if:
    FVC<20
    MIP 0 to -30
    MEP <40
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Predictors of resp failure in GBS

A 
30% patients have it
Onset to admission <7 d
FVC <60% predicted
Facial weakness
Inability to cough, lift head, lift arms, stand
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Dysautonomia in GBS

A 
70% of patients have it
Sinus tachy
Paroxysmal HTN
Ortho HOTN
Brady, AV block
Urinary retention
Ileus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Investigations in GBS

A
  • FVC
  • PVR
  • MRI whole spine with Gad (R/O acute myelopathy)
  • CBC, lytes, BUN, Cr, INR/PTT
  • LP - albumincytologic dissociation (protein >0.45, WBC <5, if WBC high check HIV)
  • EMG/NCS = absent F waves, conduction block (best 2 wks post)
  • Anti Gq1b Ab
35
Q

History GBS

A

Monophasic
85% walking by 1 year
5% go on to have chronic inflammatory demyelinating polyradiculoneuropathy
Tx: IVIG or steroids

36
Q

CIDP Defn

A
  • Most common chronic AI neuropathy
  • Progressive symmetrical proximal and distal weakness, large fibre sensory loss, areflexia, fatigue over 2 mos
  • Usually spares CN, resp, autonomic
37
Q

CIDP Dx

A
  1. EMG/NCS - acquired demyelination
  2. CBC, lytes, liver renal, thyroid B12, A1c, SPEP/UPEP, immunofixation, FLC, methylmalonic acid
  3. Maybe LP
  4. Maybe MRI spine with gab
  5. Maybe nerve U/S
38
Q

CIDP Tx

A
  1. IVIG q3 week

2. Pred 1 mg/kg

39
Q

When to suspect treatable neuropathy

A

Typical pattern

  • Distal symmetric polyneuropathy
    1. Paresthesia migrate feet to legs
    2. Lose ankle reflexes
    3. Dec sweating in feet
    4. Atrophy extensor digitorium brevis
    5. Toe flexor/extensor weakness
    6. Paresthesias at knees –> fingertips

Red flags

  1. Asymmetrical
  2. Acute onset
  3. Early motor involvement
  4. Sig autonomic involvement
40
Q

Myasthenia Gravis Features

A

Autoimmune destruction of the POST synaptic NMJ
Bimodal - young F 20s, old M 60s

Fatiguable weakness:

  1. Ocular - ptosis, binocular diplopia, pupil sparing
  2. Bulbar - dysarthria, dysphagia, chewing fatigue, head drop
  3. Resp - orthopnea
  4. Extremities - prox>distal weakness
41
Q

MG Investigations

A
  1. PFT - FVC
  2. Serum AChR Ab
  3. EMG/NCS
    - RNS (rpt nerve stimulation)
    - SFEMG
  4. CT chest - R/O thymoma
  5. CBC, lytes, Cr, TSH, CK
42
Q

Acute Management Myasthenic Crisis

A
  1. ABC
  2. Intubate if:
    FVC <20
    MIP 0 to -30
    MEP <40
43
Q

Immunosuppression myasthenia crisis

A
  1. PLEX or
  2. IVIG 2 g/kg over 2-5 d
    Hold pyridostigmine while intubated
    Caution high dose pred = worsen resp
44
Q

Maintenance Tx MG

A 
Symptoms
1. Pyridostigmine 60 TID - GI, cholinergic crisis, bronchorrhea
Disease Modifying
1. Prednisone
2. Azathioprine
3. MMF
4. PLEX
5. IVIg
6. Eculizumab
45
Q

Thymoma in MG

A

If thymoma = refer to surgery

If no thymoma - elective if <60 yo, AChRAb pos, disease <5 year

46
Q

Drugs to avoid in MG

A
  1. Anesthestic - NM
  2. ABx - FQ, AG, macrolide
  3. CV - BB, procainamide, quinine
  4. Anti PD1 MAbs - nivolumab, pembrolizumab
  5. Botulinum
  6. Chloroquine/HCQ
  7. Mg, Li
  8. Steroids - in crisis
47
Q

Headache DDx Primary

A 
Primary
1. Migraine
2. Tension
3. Trigeminal autonomic cephalalgia 
Other: cluster, paroxysmal hemicarnia, SUNCT/SUNA
Secondary
DANGEROUS
48
Q

HA Ddx Secondary

A 
Vascular
- Ischemic stroke/thrombosis
- Hemorrhage
- Dissection
- GCA
- PRES
- Pituitary apoplexy
- AVM
Space occupying
- Tumor
- Hydrocephalus
- Idiopathic intracranial HTN
Infection
- Meningitis, encephalitis, abscess
- Sinusitis, otitis
Ophtho
- Acute glaucoma
- Iritis
- Optic neuritis
49
Q

Red flags in HA

A 
SNOOP4
Systemic - fever, wt loss, IS
Neuro - s/sx
Onset - thunderclap
Older >50 
Pattern change, positional, pulsatile tinnitus, precipitated by cough/valsalva
50
Q

Secondary HA Investigations

A
  1. CT/CTA/CTV H&N
  2. MRI Brain
    Other
  3. CBC, lytes, Cr
  4. ESR/CRP - GCA
  5. DVT - CVT
  6. Blood cultures
  7. LP
51
Q

Idiopathic Intracranial HTN

A

Headache plus:
Transient visual obscurations
Pulsatile tinnitus
Weight gain

52
Q

Spontaneous intracranial HOTN

A

HA plus worse standing

53
Q

Meningitis

A

Headache
Fever
Photophobia
Neck stiffness

54
Q

HSV Encephalitis

A

HA
Fever
Encephalopathy

55
Q

GCA

A 
HA 
Fever
Weight loss
Scalp tender, jaw claudication, transient monocular vision loss
proximal myalgias
Anemia
56
Q

Reversible cerebral vasoconstriction syndrome

A

HA
Recurrent thunderclap
Pregnant
Cannabis/decongestant use

57
Q

PRES

A

HA
HTN
Cyclosporine/tac

58
Q

Dissection

A

HA
Neck pain
Horner syndrome

59
Q

Pituitary apoplexy

A 
HA
Vision loss
Diplopia
HOTN
Pregnant
60
Q

Dx Migraine w/o Aura

A

5+ HA attacks lasting 4-72 hr with no better explanation

2 of:

  1. Unilateral
  2. Pulsatile
  3. Mod-sev
  4. Aggravated by/avoid routine physical activity

PLUS 1 of:

  1. N/V
  2. Photo/phonophobia
61
Q

Tx of status migrainosus

A

Oral

  1. NSAID - ASA, diclofenac, Ibuprofen, Naproxen
  2. Acetaminophen
  3. Triptans

Parenteral

  1. IVF
  2. MgSO4
  3. Antiemetic - maxeran, domperidone
  4. Ketorolac
  5. Dexamethasone

Peripheral nerve block
Neurostimulation

NO OPIOIDS, BARBITURATES

62
Q

Multiple Sclerosis Epi

A 
F>M
Northern Europeans
Relapsing remitting type 90%
Primary progressive
Secondary progressive
63
Q

Clinically isolated syndrome

A

First demyelinating attack
Monophasic clinical episode of acute or subacute onset
Patient reported symptoms
Findings typical of MS
Reflects a focal or multifocal inflammatory demyelinating event in CNS +/- recovery
No fever or infection

If MRI lesions 70% develop MS
If non 20% develop MS

64
Q

MS Optic neuritis

A

Painful eye movements
Monocular vision and colour loss or scotoma
RAPD
1/3 mild disc swelling

65
Q

MS Brainstem/cerebellar syndrome

A 
Bilateral INO
Diplopia
Dysarthria
Ataxia
Gaze evoked nystagmus
Vertigo
Facial numbness
CN6 palsy
66
Q

Incomplete transverse myelitis

A 
Sensory loss
Asymmetric limb weakness
Urge incontinence
ED
Lhermitte - neck flexion = spinal electric shock sensation
67
Q

Uhthoff phenomenon

A

Heat exacerbation

68
Q

Ddx MS

A
  1. Demyelinating - ADEM, NMO, MOG
  2. Inflammatory - Sarcoid, SLE, Sjogrens, GPA, Behcets
  3. Infx: post infxn demyelination, HIV, PML, HTLV, syphilis, Lyme, Bartonella, TB
  4. Metabolic - B12/Cu def
  5. Lymphoma
  6. somatization
  7. Vascular - vasculitis, malformation, migraine
69
Q

Macdonald Criteria for RRMS

A
  1. MS most likely AND
  2. 1 CIS AND
  3. Dissemination in space and time
DIS
- 2+ clinical attacks OR
- 2+ lesions in 2+ of regions
DIT
- 2+ clinical attacks OR
- 1 MRI: gad enhancing and non enhancing lesions OR
- 2 MRIs - new T2/gad lesion on F/U scan OR
- CSF specific oligoclonal bands
70
Q

MS Investigations

A
  1. MRI brain and CT spine with gad
  2. LP for oligoclonal bands IgG index

Other

  • Basic lab work
  • B12, TSH, SPEP
  • ANA, ESR, CRP, ENA, ACE, ANCA
  • VDRL, LYME, HIV, HTLV
  • Visual evoked potentials
  • NMO/MOG Ab
71
Q

Treatment MS attack

A

If functional disabled = high dose CS speeds recovery

  • Optic neuritis
  • Motor weakness

Doesn’t change degree of recovery or reduce risk of future attack

Methylpred 1000 mg IV daily 3-7 d and taper
PLEX if poor steroid response

72
Q

Disease modifying therapy RRMS

A
  • Decrease relapse rate
  • Decrease MRI brain lesions
  • Lower risk conversion
Injections
- Beta interferon
- Glatiramer acetate
Oral
- Dimethyl fumarate
- Teriflunomide
- Fingolimod
- Siponimod
- Cladribine
Infusion
- Natalizumab, alemtuzumba, ocrelizumab
HSCT
Lifestyle
- Physical activity
- Stop smoking
- Vit D 4000 IU daily
73
Q

Neuro manifestations COVID

A 
Anosmia
Ageusia
Acute ischemic stroke
Encephalopathy/encephalomyelitis
HA
Mylagia, rhabdo
ICH
GBS
Bell's palsy
74
Q

Encephalopathy Management

A
  1. ABC
  2. Thiamine, dextrose, Naloxone
  3. Hyperthermia - cooling blankets, antipyretics
  4. Consider empiric ABx/antivirals
    Inv
    - Tox screen
    - CT/MRI head
    - EEG
    - LP
75
Q

Herpes Encephalitis

A 
HSV1 reactivation
<1 wk AMS, aphasia, ataxia, memory, focal seizure
Inv
- MRI
- LP - inc RBC, lymph's, glucose normal
- EEG - high amp slow waves
- HSV CSF PCR
76
Q

Otologic Vertigo

A 
Sx
- Hearing loss, Tinnitus, Aural fullness
- Severe vertigo
- Head trauma
- With head postures, cough
Exam
- HINTS benign
- Unidirectional nystagmus
- Dix Hallpike positive
Ancillary
- Audiology
- Vestibular testing
- CT temporal bone
77
Q

Neurologic Vertigo

A 
Sx
- Diplopia
- Dysphagia, dysarthria
- Hemiparesis, hemisensory loss
- Migraine, MS, stroke
Exam
- HINTS concerning
- Direction changing nystagmus
- Skew deviation
- Horner
- Ataxia
- Focal weakness
- Gait instability
Ancillary
- MRI brain
78
Q

Medical Vertigo

A 
Sx
- Syncope, SOB, palps
- Only when standing
Exam
- Murmur
- Ortho HOTN
Ancillary
- Holter, echo, lytes, med review
79
Q

Psychogenic vertigo

A 
Sx
- Constant for mos
- Panic attacks
Exam
- Positive signs: Hoover sign, distractibility, suggestibility, entrainment, waxing/waning
80
Q

HINTS Exam

A

Peripheral vs central vertigo

  1. Head impulse test
    - P: abnormal, corrective saccade
    - C - normal, no correction
  2. Nystagmus
    - P: unidirectional, horizontal
    - C: horizontal, direction changing, vertical, tosional
  3. Test of Skew
    - P: no skew deviation
    - C: skew deviation
81
Q

Lateral medullary syndrome (Wallenberg)

A 
Infarct of vertebral or PICA
- N/V, vertigo
- Ipsilateral Horner
- Ipsilateral face pain/temp loss
- Contralateral body pain/temp loss
- Ipsilateral cerebellar ataxia
- Ipsilateral dysphagia/dysarthria
- Hiccups
NO LIMB WEAKNESS
82
Q

Horner’s syndrome

A

Miosis - constrict
Ptosis - droopy lid
Anhidrosis - no sweat
Damage to sympathetic nerves

83
Q

Bell’s Palsy

A

Unilateral drooping
Ptosis
Cannot close eye

84
Q

Pregnancy considerations

A 
Epilepsy
- Avoid AEDs - valproate
- Drug level monitor
MS
- Improved relapse rate, inc risk PP 3-4 mos
- Methylpred tx
- Glatiramer and interferon best for immediate pregnancy
HA
- Tylenol, sumatriptan, nerve block, neurostimulation
Stroke
- Risk permpartum to 6 weeks post
- avoid gad
- offer TPA/EVT

RCE 2021 (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions